2018 MEETING OF THE WORLD CONGRESS ON DENTAL

TRAUMATOLOGY Gideon Holan, DMD

Pulp Aspects of Traumatic

Dental Injuries in Primary
Incisors: Dark Coronal
Discoloration

ABSTRACT
Dark coronal discoloration is a common outcome of traumatic dental injuries in primary
SIGNIFICANCE
incisors. However, there are only a few research studies on the mechanism that causes dark
discoloration, the condition of the pulp, and the preferred treatment of such teeth. This article ---.
is a summary of the author’s research studies and personal experience regarding dark coronal
discoloration of traumatized primary incisors. (J Endod 2019;-:1–3.)

KEY WORDS:
Dark discoloration; dental trauma; primary incisor

Coronal discoloration is a common outcome of traumatic dental injuries (TDIs) in primary incisors. Coronal
discoloration can be observed better and earlier by transillumination when the light source is directed to
the labial surface of the crown and the tooth is observed through its palatal aspect using a dental mirror.
Generally, there are 3 types of discoloration. The pink hue may represent either internal
hemorrhage or internal coronal resorption. Yellow discoloration usually represents pulp canal obliteration
or calcific metamorphosis. Dark discoloration is the most common reaction to TDI in primary incisors and
the most controversial regarding its interpretation and appropriate treatment (Fig. 1). It is usually seen 10
to 14 days after the injury. There is a wide range of shades that can be termed dark discoloration, ranging
from light brown to gray and black. However, there is no established relationship between the
discoloration of anterior teeth and the pathology of the pulp.1

What Makes the Tooth Change Its Color?

One theory claimed that blood may be forced into the dentinal tubules.2–6 However, this seems to be
impossible. The diameter of the red blood cell is 7 mm. It is concave in shape, which makes it flexible and From the Department of Pediatric
Dentistry, The Hebrew University–
able to pass through channels 5 mm across at a pressure as low as 4 mm Hg.7 However, the dentin tubule
Hadassah School of Dental Medicine,
diameter is approximately 2–3 mm at the pulp side.8 Another theory claims that dark discoloration results Jerusalem, Israel
from diffusion of blood pigments into the dentinal tubules.9–11 However, this theory has not been
Presented at the 20th World Congress on
supported by any investigations. In an in vitro study,12 investigators succeeded to force hematin into the Dental Traumatology, August 15–18,
dentin tubules of permanent premolars. However, the purpose of the article was to describe a technique 2018, San Diego, CA.
aimed to prepare model teeth for bleaching. In this technique, whole blood or erythrocytes were inserted Address requests for reprints to Dr Gideon
in the pulp chamber, and the teeth were centrifuged at 3500 rpm twice daily for 25 minutes over 3 days. Holan, Department of Pediatric Dentistry,
This obviously is not the case in traumatized primary incisors. A third theory13 claimed that hemosiderin or The Hebrew University–Hadassah School
necrotic pulp toxins stain the dentin. A similar theory14 claimed that discoloration is associated with the of Dental Medicine, P.O. Box 12272,
Jerusalem 91120, Israel.
formation of a surface film (of iron) on the dentin. This theory can be compared with the black pigment in
E-mail address: gideonH@ekmd.huji.ac.il
black extrinsic tooth stain that is the result of a ferric salt, probably ferric sulfide, formed by the reaction 0099-2399/$ - see front matter
between hydrogen sulfide produced by bacterial action and iron in the saliva or gingival exudate.15 To
Copyright © 2019 John Wiley & Sons A/S
prove that this is a mechanism of coronal discoloration after TDI, it has to be confirmed that the pulp in and American Association of
dark discolored primary incisors is infected by microorganisms that can produce hydrogen sulfide. The Endodontists. This article is being
author of this article measured and calculated the proportions between the mesiodistal widths of the published concurrently in Dental
crown of a dark discolored primary incisor on a periapical radiograph and the width of the coronal pulp. Traumatology. The articles are identical.
Either citation can be used when citing this
These were compared with the proportions between the widths of the crown of the same tooth in a article.
clinical photograph taken from the palatal aspect and the width of the discolored part of the crown. The https://doi.org/10.1016/
proportions were found to be the same, indicating that the dark color was restricted to the pulp and did j.joen.2019.05.012

JOE  Volume -, Number -, - 2019 Pulp Aspects of Traumatic Dental Injuries 1


FIGURE 1 – A clinical view of the maxillary primary central incisors of a 5-year 6-month-old boy. His parents first
noticed discoloration 21 months earlier but could not recall any injury to the teeth. The teeth are asymptomatic and have
different dark shades.
not invade the dentin. Moreover, a dark
discolored tooth that had to be extracted
because of infection was cut into 2 halves
along the long axis of the tooth. The necrotic
pulp was gently removed, and slight
unintentional scratches of the dentin showed
bright dentin without any sign of discoloration.
This again indicates that pigments that discolor
the tooth do not invade the dentinal tubules.
Several extracted dark discolored teeth
were cut as described, and the exposed pulp
aspects of the dentin were evaluated by an
inductively coupled plasma mass
spectroscopy machine, which is a powerful
method for the detection of metals and
nonmetals at concentrations as low as 1 part in
1015 on solid surfaces. The main elements
found in the specimens were carbon, calcium,
and phosphorus. Low concentrations of
oxygen, magnesium, and sodium were also
found. Iron was found in only 1 specimen and
at an extremely low concentration. This finding
raises doubts about the contribution of iron to
coronal discoloration. Another interesting and
yet unexplained finding was the complete
disappearance of the dark discoloration in dark
discolored teeth that were extracted and left in
a dry environment.
question to be answered is as follows: Why
do some dark discolored teeth remain
asymptomatic until normal exfoliation despite
the pulp being necrotic, whereas other teeth
present sooner or later with signs of
infection? There are 2 possible explanations:
the first hypothesis predicts that the pulp in
asymptomatic teeth is necrotic but not
infected, a condition known as sterile
necrosis. Signs will only appear sometime
after the necrotic pulp becomes infected.
The second hypothesis claims that the
necrotic pulp is infected by low-virulence
microorganisms. Signs will not appear as
long as the host’s resistance remains
unimpaired.
How Should Dark Discolored
Primary Teeth Be Treated?
After several years of performing endodontic
treatment in every dark discolored primary
incisor even if otherwise asymptomatic, the
author changed his approach, and maxillary
primary incisors that presented dark
discoloration of the crown after traumatic
injuries were left untreated and were regularly
TABLE 1 - Distribution of Teeth with Different Crown Discoloration and Type of External Root Resorption
reviewed. The findings of the follow-ups have
been summarized (Table 1) and published.17
Ninety-seven primary incisors with no clinical
or radiographic signs other than dark
discoloration of the crown were reviewed in
73 children (46 boys and 27 girls, ratio 5
1.7:1). The follow-up time ranged from 12–75
months, and the mean follow-up was more
than 36 months. Twenty-eight teeth were
followed until eruption of the permanent
successors with a range of 17–75 months
and a mean of 42 months. In 50 teeth (52%),
the dark color faded or became yellowish. In
47 teeth (48%), the color remained dark. In
43% (20/47 teeth), the necrotic pulp became
infected (sinus tract or swelling) and required
root canal treatment or extraction. Twenty-six
teeth (56%) remained asymptomatic until the
end of the follow-up period. These findings
evoked a dilemma. On the one hand, root
canal treatment seems to have a higher
success rate when performed in
asymptomatic teeth than in teeth with a
periapical radiolucency and external root
resorption. Conversely, teeth with dark
discoloration may remain asymptomatic until
natural exfoliation and may never develop any
pathologic sign to indicate the need for root
canal treatment or extraction. The question
then was as follows: Is there a difference
between doing root canal treatment and just
follow-up of dark discolored traumatized
primary incisors? The change of policy
regarding the preferred treatment of dark
discolored traumatized primary teeth that are
otherwise asymptomatic and the long term
follow-up of the teeth in both groups allowed
a comparison to be studied. The teeth were
divided into 2 groups: the root canal
treatment (RCT) group and the follow-up only
(FU) group. The results of this comparison
were published in 2006.18 Of the original 48
incisors in the RCT group, 25 teeth were

What Is the Condition of the Pulp in Tooth color

Teeth with Dark Coronal
Yellowish shades
Discoloration?
It is clear that if the dark discoloration fades, Gray- Brown- Black-gray-
Radiographic
then the pulp is viable. It is also clear that if a Bright Yellow yellow yellow Total brown Total
appearance of
dark discolored traumatized primary incisor the pulp n (%) n (%) n (%) n (%) N (%) n (%) N (%)
presents with sinus tract or fistula, the pulp is Internal resorption 0 (0) 0 (0) 0 (0) 0 (0) 0 (0) 2 (4) 2 (2)
necrotic and infected. The interesting Arrest of dentin 0 (0) 0 (0) 0 (0) 1 (9) 1 (2) 14 (30) 15 (16)
question relates to the condition of the pulp apposition
in traumatized primary incisors that are Pulp canal 3 (75) 22 (85) 5 (56) 9 (82) 39 (78) 3 (6) 42 (43)
completely asymptomatic but have dark obliteration
coronal discoloration. A study16 describing Tubelike 0 (0) 3 (12) 2 (22) 1 (9) 6 (12) 1 (2) 7 (7)
the condition of the pulp in such teeth that mineralization
Normal 1 (25) 1 (4) 2 (22) 0 (0) 4 (8) 27 (57) 31 (32)
were treated endodontically found 98% (47/
Total 4 (100) 26 (100) 9 (100) 11 (100) 50 (100) 47 (100) 97 (100)
48 teeth) had a necrotic pulp. The next

2 Holan JOE  Volume -, Number -, - 2019

available for long term follow-up until the
eruption of the permanent successor. Of the
97 incisors in the FU group, 28 teeth were
available for follow-up until the eruption of the
permanent successor. The following
parameters were evaluated in both groups:
the need for early extraction of the primary
incisor, and, for the permanent successors,
early or late eruption, ectopic eruption, and
enamel defects were assessed. Chi-square
analysis comparing both groups showed no
significant differences between the RCT and
JOE  Volume -, Number -, - 2019
FU groups. It was concluded that dark CONCLUSION
discolored primary incisors that are otherwise
Dark coronal discoloration in primary incisors
asymptomatic can be left untreated and
after traumatic injury is a sign of pathology (ie,
followed without increased risk for their
pulp necrosis). However, this does not require
permanent successors. Intervention is only
removal of the pulp unless clear clinical
needed in cases of infection expressed by
evidence of infection of the pulp is present.
swelling or a sinus tract. In these cases, the
treatment of choice (root canal treatment or
extraction) is based on the clinical and
radiographic findings and on the operator’s
ACKNOWLEDGMENTS
judgment for each individual patient The author denies any conflicts of interest
and tooth. related to this study.
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Pulp Aspects of Traumatic Dental Injuries 3